Last Month to Submit Program Year 2020 Attestations

Tuesday, April 6, 2021

NC-MIPS is accepting Program Year 2020 Stage 3 Meaningful Use (MU) attestations. 

Providers have until April 30, 2021, to submit a complete and accurate attestation for Program Year 2020. After that no changes can be made. 

In Program Year 2020, eligible professionals (EP) may use a 90-day or full calendar year (Jan. 1, 2020 – Dec. 31, 2020) MU and clinical quality measure (CQM) reporting period. 

EPs who attested with another state should email prior to attesting with North Carolina for Program Year 2020.

To participate in Program Year 2020, all EPs must meet the following eligibility criteria:

  1. Have a 2015 Edition of certified EHR technology (CEHRT) 
  2. Meet the required Medicaid patient volume (PV) threshold of 30%; pediatricians may qualify for a reduced payment with 20% Medicaid PV. Note: EPs who were paid for Program Year 2019 using a 90-day patient volume reporting period from calendar year 2019 have the option to use the same patient volume reporting period to attest for Program Year 2020. 
  3. Meet MU and CQMs requirements. In Program Year 2020, EPs will be attesting to Stage 3 MU and 2020 CQMs.

Program Year 2020 Webinar Series

The NC Medicaid EHR Incentive Program’s webinar series has been updated to reflect the rules and regulations for Program Year 2020. 

The webinars are designed with the busy provider in mind, so most of them are about five minutes long. Each short webinar explains a different piece of the attestation process such as updating a CEHRT number, updating a username in NC-MIPS and submitting an attestation. 

Other webinar topics include patient volume, audits, MU and CQMs in Program Year 2020 and more. These webinars can be found on the Resources and Webinars tab of the program website

The Security Risk Analysis (SRA)

States must comply with federal requirements to ensure EPs who attest for EHR incentive payments do so in accordance with the Centers for Medicare and Medicaid Services’ (CMS) rules and regulations. The NC Medicaid EHR Incentive Program investigation team serves the purpose of detecting improper payments and takes corrective action in the case improper payments were issued. All EPs who receive an EHR incentive payment are subject to audit and must keep all documentation supporting their attestation for six years post-payment.  

NC Medicaid EHR Incentive Program investigators are sharing tips from CMS to prepare for Objective 1: Protect Patient Health Information. Per CMS, to meet this objective, “EPs must attest YES to conducting or reviewing an SRA and implementing security updates as necessary and correcting identified security deficiencies to meet this measure.” 

Every EP must include, at minimum, the following five items in her/his SRA. These items must be completed during the calendar year of her/his MU reporting period: 

  1. Define the scope of the risk analysis.
  2. Identify potential threats and vulnerabilities to patient privacy.
  3. Describe how to protect against potential threats (physical, administrative and technical safeguards).
  4. Review and update the risk analysis on a periodic basis.
  5. Develop a corrective action plan.

EPs selected for audit who cannot provide documentation that their SRA included the above five items will fail the audit and will be required to return the incentive payment received for that program year. 

Please note, SRAs are not synonymous to a practice’s operating procedures or policies. The SRA is an independent security review and analysis of an individual or practice’s EHR. 

HHS’ Office for Civil Rights (OCR) and the Office of the National Coordinator for Health Information Technology (ONC) created an SRA tool, which when completed, satisfies the objective’s requirements. Program Investigators recommend EPs review HHS’ guidance and/or complete the SRA tool prior to attesting to ensure compliance.

ONC updated the SRA tool to Version 3.2 on Sept. 17, 2020. This version includes the following enhanced features: flexible section navigation, improved user interface scaling, risk report export, addition of “Details” field to each question, preventative measures for file corruption/file recovery system and “Save as” functionality. The updated features do not change the content of the SRA.

Program Year 2021 Announcements

Program Year 2021 will be the last year returning EPs may attest to the NC Medicaid EHR Incentive Program. NC-MIPS is scheduled to begin accepting Program Year 2021 attestations May 3, 2021. All Program Year 2021 attestations must be submitted through NC-MIPS by Oct. 31, 2021. Program staff guarantee to review the provider’s attestation, and conduct outreach if needed, if we receive the signed attestation and required documentation via email by Aug. 31, 2021. EPs should plan to attest for Program Year 2021 as soon as possible to ensure timely processing and payment. No Program Year 2021 attestations will be accepted after Oct. 31, 2021.

In Program Year 2021, SRAs must be completed by Dec. 31, 2021. Because NC-MIPS must close by Oct. 31, 2021, the system has been updated to allow EPs to submit a Program Year 2021 attestation prior to having completed the SRA. EPs that submit in NC-MIPS prior to completing their SRA must attest that they will complete the SRA prior to Dec. 31, 2021.

To be eligible to apply for an NC Medicaid EHR incentive payment, each year of attestation (including Program Year 2021), an EP must:

  1. Have a certified EHR technology.
    • In Program Year 2021, all EPs must have a 2015 Edition of certified EHR technology.
    • Please see ONC’s Certified Health IT Product List (CHPL) to see if it meets certification criteria. EPs should work with their EHR vendor if they are unsure of what version of EHR they have in their practice. 
    • Here is a two-minute video that shows step-by-step how to pull the CEHRT ID number from CHPL and update that number on CMS' Registration and Attestation (R&A) System: An Overview of CMS EHR Certification ID Numbers.
  2. Meet the required Medicaid PV threshold.
    • All EPs must have at least 30 percent Medicaid-enrolled encounters in a consecutive 90-day period.
    • Pediatricians may qualify for a reduced payment if they have 20 percent Medicaid-enrolled encounters. 
  3. Meet MU and CQM requirements. In Program Year 2021, EPs will be attesting to Stage 3 MU and 2021 CQMs. The Stage 3 MU objectives and measures will remain unaltered from Program Year 2020. The CQMs have been updated for Program Year 2021.
    • Click here to see the Program Year 2020 and 2021 Stage 3 MU Specification Sheets from CMS.
    • Click here to see the 2021 CQMs.
  4. Have participated successfully at least once in program years 2011-2016. Providers who successfully attested at least once by the end of Program Year 2016 and have not received all six incentive payments may be eligible to apply for Program Year 2021. Please visit the program website’s “Are You Eligible” tab for a list of all providers who have participated at least once but less than six years in the NC Medicaid EHR Incentive Program to date. NOTE: All EPs on the list of past participants have met this requirement.
    • EPs must have successfully attested at least once (to Adopt/Implement/Upgrade (AIU) or MU) by Program Year 2016 to be able to participate in the NC Medicaid EHR Incentive Program in program years 2017-2021. A denied attestation does not count as a successful attestation. 
    • If you meet all the requirements listed above, but are unsure if you successfully attested prior to the end of Program Year 2016, please send an email with your NPI to, and we will look it up for you.
  5. Be an eligible provider type. These provider types include:
    • Physicians
    • Nurse practitioners
    • Certified nurse midwives
    • Dentists
    • Physician Assistants (PAs) who furnish services in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) that is led by a PA.


NCTracks Contact Center: 800-688-6696